六例肾移植术后人细小病毒B19感染的临床特点和疗效分析  

Clinical characteristics and treatment of six kidney recipients with human parvovirus B19 infection

作　　者：高佩娟 石运莹[1] 普文申 陶冶[1] GAO Peijuan;SHI Yunying;PU Wenshen;TAO Ye(Department of Nephrology,West China Hospital,Sichuan University,Chengdu,Sichuan 610041,P.R.China)

机构地区：[1]四川大学华西医院肾脏内科

出　　处：《华西医学》2019年第7期769-776,共8页West China Medical Journal

摘　　要：目的探究肾移植术后人细小病毒B19(human parvovirusB19,HPV-B19)感染导致纯红细胞再生障碍性贫血(pure red cell aplasia,PRCA)的诊断、临床特点、治疗及转归。方法回顾性分析了2018年5月-2019年4月四川大学华西医院肾脏移植中心肾移植术后6例HPV-B19感染所致PRCA患者的临床诊治经过。结果6例HPV-B19感染患者表现出明显的贫血相关症状,缺乏皮疹、关节疼痛等其他病毒感染表现;5例患者接受了1个疗程静脉注射免疫球蛋白(intravenous immunoglobulin,IVIG)治疗后血红蛋白水平恢复,乏力、疲倦等贫血症状明显改善,1例患者在2个疗程治疗后无缓解,重复第3个疗程治疗时联合更换他克莫司为环孢霉素(cyclosporine,CsA)后贫血明显改善;1例复发患者重复1个疗程治疗后重度贫血再次缓解。随访患者网织红细胞第1次上升至>0.084×1012/L距离IVIG疗程结束的中位时间为3.50(1.25,5.00)d,血红蛋白升高30g/L距离IVIG治疗结束所需的中位时间为16.00(9.25,31.25)d。治疗过程中患者移植肾功能稳定,未发生严重不良反应。结论肾移植术后HPV-B19感染所致PRCA主要表现贫血相关症状,缺乏其他病毒感染表现;HPV-B19DNA检测结合血常规、网织红细胞计数及骨髓细胞学涂片(也可无)可以诊断HPV-B19感染;使用大剂量IVIG安全有效,感染复发时重复使用依然有效;对于IVIG无效的难治性PRCA,联合他克莫司更换为CsA可以有效改善贫血,且并不影响移植肾功能的恢复。Objective To investigate the diagnosis,clinical features,treatment and outcome of pure red cell aplasia (PRCA) caused by human parvovirus B19 (HPV-B19) infection in kidney recipients. Method The clinical courses of six patients with PRCA caused by HPV-B19 infection after renal transplantation in West China Hospital between May 2018 and April 2019 were retrospectively investigated. Results The six patients showed obvious anemia symptoms,lacking rash,joint pain and other clinical symptoms of viral infection. The hemoglobin level of five patients got totally remission from a course of intravenous immunoglobulin (IVIG) treatment,and anemia symptoms like fatigue, weakness got notable improvement. One patient had no improvement after two courses of IVIG treatment,and his anemia was significantly improved after the third IVIG course combined with immunosuppressant conversion(from tacrolimus to cyclosporine),and one patient with recurrence accepted a repeated course of IVIG treatment and obtained remission of severe anemia again. The median time of reticulocyte firstly rose to above 0.084×1012/L from the day of IVIG treatment ended was 3.50 (1.25,5.00) days,and the median time required for a 30 g/L increase in hemoglobin to the end of IVIG treatment was 16.00 (9.25,31.25) days. No serious adverse reactions occurred and all patients had stable graft function. Conclusions The main clinical manifestations of PRCA caused by HPV-B19 infection after kidney transplantation are anemia symptoms,lacking other clinical symptoms of viral infection. HPV-B19 DNA detection combined with blood routine examination,reticulocyte count and bone marrow cytology (or none) can diagnose HPV-B19 infection. High dose of IVIG is effective and safe,and a repeated course is still effective when the infection recurs. For refractory PRCA that IVIG monotherapy fail,a combination with conversion from tacrolimus to cyclosporine can effectively improve the anemia without graft dysfunction.

关 键 词：肾移植 人细小病毒B19 纯红细胞再生障碍性贫血 静脉注射免疫球蛋白 免疫抑制剂 

分 类 号：R699.2[医药卫生—泌尿科学] R511[医药卫生—外科学]